- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,816.00 / $5,194.80 / $18,935.30
| Facility | | $3,816.00 | $5,194.80 | $18,935.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.00 / $4,284.00 / $4,680.00
| Professional | | $2,160.00 | $4,284.00 | $4,680.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,768.48 / $6,437.88 / $9,049.32
| Facility | | $3,768.48 | $6,437.88 | $9,049.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.70 / $4,140.00 / $5,184.00
| Professional | | $657.70 | $4,140.00 | $5,184.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,600.00 / $3,600.00 / $3,600.00
| Facility | | $3,600.00 | $3,600.00 | $3,600.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,340.00 / $25,424.75 / $27,331.02
| Facility | | $2,340.00 | $25,424.75 | $27,331.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,512.00 / $2,052.36 / $4,680.00
| Professional | | $1,512.00 | $2,052.36 | $4,680.00 |